Headaches, Guilt, and Wyclef Jean–Part II (Updated–October 3, 2017)

Cite Soleil–June 29, 2016 (Photo by John Carroll)

I returned to Peoria from Haiti in early May because of my persistent headaches and the abnormal CAT scan done in Port-au-Prince. I felt pretty soft leaving Haiti where I was surrounded every day by very sick kids with their worried moms. People living in Cite Soleil have no access to meaningful medical care.

My good wife Maria spoke with a medical student roommate and friend of mine, Ed Pegg, who has practiced neurology for over 30 years. Ed ordered an MRI scan for me to be done at OSF-SFMC in Peoria when I returned. My main worry was finding a “space-occupying lesion” in my brain (brain tumor) as the cause of six months of headaches that woke me up from a sound sleep almost every day.

I have a strong aversion going to the doctor. I am a diagnostic and therapeutic nihilist regarding my own medical care. Most mysterious illnesses usually reveal themselves and dictate treatment if any is needed. And I don’t enjoy paying thousands of dollars for overpriced tests that may not be needed and may, in fact, be dangerous. But I don’t practice medicine like this because my medical decision-making for myself is myopic and patients should know the options available for them.

Also, our medical system in the US is too complicated for me. A recent New England Journal of Medicine article stated that the three features of a health care system that may impede people from getting timely medical care are : “The cost of care and its affordability for individuals, the administrative burden (or hassle) that people confront as they obtain and receive care, and disparities or inequities in the delivery of care based on income, educational attainment, race or ethnic background…”

I absolutely despise the “administrative burden” associated with getting medical care. I don’t understand medical insurance very well and don’t want to talk with doctor offices or insurance companies on the phone. I dislike terms like co-payments, deductibles, and premiums. Health insurance exchanges mean nothing to me. They all sound onerous. And what is even worse, I DON’T want to learn about this mumbo-jumbo for my patients or for me. I want people to get the best care possible without worrying how they will pay for it.

Also, the cost of care and affordability is definitively a deterrent for me (and millions of others) to access medical care. I pay 800 dollars a month for Blue Cross-Blue Shield (BC/BS) insurance with a high deductible. I feel I am being royally ripped off.

After arriving home, I was given a speedy appointment for a Brain MRI with contrast at OSF-SFMC. The MRI technician was efficient and the entire MRI took about 30 minutes. The MRI was read by a young radiology resident. It showed the obvious cerebral infarct of indeterminate age without any associated pathology. I breathed a huge sigh of relief. Even with the CAT scan and MRI evidence of infarcted brain tissue, I felt very fortunate and blessed that nothing worse was found. (During the last four months, my headaches have dwindled down to about one per month.)

A few weeks later my MRI bill arrived from OSF and was for 2,888 dollars. This bill for the MRI seemed exorbitant to me. This MRI which was deemed medically necessary by my neurologist is typically covered by health insurance plans. If deductibles are met, a typical out of pocket copay for the MRI would be $100. But my deductible is high, and so BC/BS will pay for none of my bill.

I called OSF billing and spoke with a lady in Billings, Montana (an appropriately named city). I offered her what I thought was a reasonable amount of payment for the MRI. She was polite but stated that she could not lower the bill. I followed up with a phone call to OSF billing in Peoria and offered the same amount of money. She stated the same–she could not accept my offer but did say she would send me papers for financial aid from OSF’s Charity. When the papers arrived in the mail, they were incredibly detailed, and I determined I wouldn’t qualify.

I realize that I am fortunate to have ANY medical insurance, but I do feel “underinsured” due to my large deductible in spite of my premium that I pay each month. And I don’t qualify for government insurance for the poor or for OSF’s Charity.

The inability to pay freezes many people with serious medical problems from getting medical care. They don’t want to go bankrupt, and so their health suffers.

Diagnostic imaging like MRI is charged at a very high rate to offset underpayment for other lines of health care. For example, OSF-SFMC closed their psychiatric unit years ago because it was not a money maker. I think people like me with private insurance or self-pay are paying more for tests like MRI so that medical centers have a good bottom line. OSF HealthCare System profits two years ago was 200 million dollars.

It is very difficult to shop around and be “smart consumers” when one needs quick medical diagnosis or treatment. There usually is no price tag before hand, and the consumer (patient) is expected to pay the whole amount billed. Ironically in Haiti, one of the most dysfunctional countries on earth, I knew the exact price of my CAT scan BEFORE I had the CAT scan.

How was the bill for my MRI derived? Where did it come from? I think it was derived from the “chargemaster”. All hospitals have a master price list called a chargemaster. The chargemaster is what the patient pays for a certain service. Almost no one in any hospital can explain how prices are set on the chargemaster. And, in my opinion, the chargemaster is not based on any truth.

The chargemaster typically serves as the starting point for negotiations with patients and health insurance providers of what amount of money will actually be paid to the hospital. It is described as “the central mechanism of the revenue cycle” of a hospital. (Wikipedia)

Chargemasters gained national attention in early 2013, when in short succession, there were two important publications made. First, there was a Time magazine cover story published February 20, 2013, titled “Bitter Pill: Why Medical Bills Are Killing Us”, in which reporter Steven Brill examined the overlooked role that chargemasters played in the American health care system’s cost crisis, asserting that they routinely listed extremely high prices “devoid of any calculation related to cost”, and were generally regarded as “fiction” in the healthcare industry, despite their significant role in setting prices for both insured and uninsured patients alike. Then, a couple of months later, the Centers for Medicare and Medicaid Services published inpatient prices for hospitals across the country in a publicly available format.”The ‘full charges’ reflected on hospital charge masters are unconscionable,” wrote George A. Nation III in a 2005 piece for the Kentucky Law Journal. (Internet Source)

Elizabeth Rosenthal MD: “As health care became a business, hospitals could have spent their operating surpluses on raising pay for nurses and orderlies, or reducing list prices for patients. But there was not much commercial incentive to do that. “There are an infinite number of ways to spend: amenities, scanners, higher salaries,” said James Robinson, a health economist at the University of California, Berkeley. “So they build more. They’re like Four Seasons Hotels, with valet parking and chandeliers. Then they go to Congress and say Medicaid and Medicare aren’t paying us enough, my margins are low, the CEO doesn’t make much money compared to the private sector.”

“As hospitals became lavish, executive salaries did too. Top brass of hospitals received packages that included golden parachutes, cars, and funding for their kids’ education. More than two-thirds of the country’s hospitals are not-for-profit, and IRS rules state that nonprofit CEOs should receive only “reasonable compensation,” which it advises should be determined in part by considering salaries at similar organizations. But, as also occurs in the corporate world, the CEO typically picks the compensation consultant and controls who is on the board.”

“Total cash compensation for hospital CEOs grew an average of 24.2 percent from 2011 to 2012 alone, which increasingly includes bonuses as well. No surprise. Those bonuses are typically linked to criteria such as “finance,” “quality,” “profit,” “admissions growth,” and “increase in net funds,” not medical goalposts like reducing blood infections or bedsores…”( OSF’s CEO made over 2 million dollars a year several years ago and OSF’s Board of Directors are paid extremely well.)

So what do we need to do when seeking medical care in the United States with our broken medical system? How do we pay for our care? We all need to know how much a procedure costs before we have the procedure. It is important to scrutinize itemized medical bills because studies have shown these bills have errors 50-90% of the time. (Fifteen years ago we reviewed the bills of six Haitian Hearts patients at OSF-SFMC and found overcharges of 44,000 dollars.)

Rosenthal writes : “One of the oldest and most extensive of the medical pricing sites is online at www.healthcarebluebook.com. Based on the data it collects from patients, insurers, and companies, it calculates a “fair price” for a large number of procedures, in different geographic locations. It is clear about what aspects of the care its “fair price” covers, such as whether or not it includes anesthesiologist fees. Many doctors and hospitals charge several times the Healthcare Bluebook “fair price.” If you enter your zip code, it will identify which options in your area are at or below the “fair price,” and which are far above. It offers cost-saving tips, such as whether your procedure could be performed as an outpatient for less money. Healthcare Bluebook’s “fair price” may also be useful in bargaining with your hospital or insurer over whether charges are reasonable.”

I went to this website and found the price for an MRI (with contrast). According to this site, a fair price for an MRI (with contrast) is 1,102 dollars.

So I wrote the following letter to OSF Billing which went to an address in Chicago:

Dear Sir or Madam,

My account number is:_________.

Please send me an itemized bill.

I am writing to protest what I regard as excessive charges for my MRI scan done at OSF-SFMC in Peoria.

I had a brain MRI with contrast and was billed 2,886 dollars. www.healthcarebluebook.com states that a “fair price” for this scan would be 1,102 dollars.

Before sending in any payment, I am requesting that your billing and coding department review my bill and revise my charges. I am willing to pay 1,102 dollars with a credit card now.

Sincerely,

John A. Carroll

In conclusion, we need a health care system that works. We suffer and die from lack of accessibility, excessive administration (medical insurance and medical center), cost of medical care (chargemaster), and inequities of delivery of care (See Haiti for an extreme example of all of these hurdles.)

Why not Medicare for all–a single-payer system and knock out as many administrators and business people taking our money from the current “gravy train”.

Finally, I agree with Dennis Kucinich, a former US Representative from Ohio, when he stated, “It’s time we ended this thought that health care is a privilege. It is a basic right…Think for a moment if Lincoln had decided, well, you know, there’s just too much resistance to this idea of emancipation.”

October 3, 2017

I received this letter from OSF Patient Accounts in late September:

Dear John Carroll:

We have investigated your concern with regards to your pricing question. The prices have been investigated and are accurate.

We deeply value your relationship with OSF Healthcare System and are committed to providing you with highest level of care.

If you have any questions, please contact us at (309) 683-6750.

Warm Regards,

First Name

Patient Accounts

OSF Healthcare System

October 10, 2017

I spoke with Patient Accounts at OSF again today.

The lady on the phone was very polite. I repeated that I would pay OSF $1,102 dollars by credit card over the phone. She told me that $500 had been taken off my bill by her supervisor since my Blue Cross/Blue Shield (BC/BS) paid none of my bill. I think she was implying that OSF would charge BC/BS this same amount–about $2,300 dollars for the MRI.

I politely reiterated to the lady that I would be glad to pay $1,102 dollars and asked her to speak with her supervisor.

This afternoon her supervisor called me. He was very polite on the phone but said that he would not change the offer of $500 off as stated above. He told me that MRI’s charges vary a lot depending on which part of the country we live in.

I told him that I was unwilling to move from my offer.

Today, OSF had a press conference at the Spalding Diocesan Center and announced that BC/BS basically fired OSF-SFMC from their insurance network. Concurrently Unity Point-Methodist stated at another news conference that BC/BS is allowing Unity Point-Methodist into their insurance network for the first time in 30 years.

October 19, 2017

See this article from Vox. The average price for an MRI in the United States is $1,100.00. This is what I am offering OSF.

dear Dr.Carroll,
I have read your last two blogs with great interest. You have shed some light on pricing of medical procedures. As people age our possibility of needed health care increases. Most of us live on company pensions and/or SSpensions. Having lost my husband two years ago my income is even more limited. I find myself questioning how necessary is it for me to see a doctor or hospital because prices are so restrictive. I am glad to know that I do have insurance but the co pays and out of pocket charges are more than I can pay. I am hoping that something will be done to rein in these charges. Thank you for your input, at least I know I am not alone in my thinking

I am one of your devouted fans and am always moved by your selfless work in Haiti for the poor. Naturally I am relieved to read that you are relieved after this last MRI but have you figured out yet why you were having those painful headaches?

I, like others who read your first part of this blog, would have preferred to be tipped off that this was historical information, i.e., we find out in the second part that it occurred in May. We are relieved, as Michelle stated above, that you have had follow up testing which cleared up your questions and concerns.

I ask you how your colleagues receive the idea of socialized medicine, which is what single-payer is, no? You are a physician, though not typical, by any means. You may have some idea of how more typical American physicians view the idea, though. You may have personal contact with physicians from countries with socialized medicine. What have they had to say?

Your experience with our system has you wondering about alternatives, which is understandable. In a single-payer system, someone is making decisions which you may not like. The resources are not infinite, so someone decides who merits what. If your patient is one deemed not worthy of your prescribed treatment, you may decide that system is not a panacea, either.

Your choice of Kucinich to quote is puzzling. During his run for president he seemed to be someone who may have started as a devout Catholic, but had the wheels fall off of that bus somewhere along the line.

Thank you writing this and I’m relieved your headaches are lessening. I live in Australia and am extremely grateful for our Medicare system which means everyone can access free health care. Private health insurance is taken out by people who want their treatment by specified doctors in private hospitals. As a Medicare patient, (free), patients may need to wait years on a waiting list before receiving their hip replacement or elective surgeries for example, however emergencies etc are treated the same for public and private patients. If Australia can manage this for our residents, I can’t understand why USA can’t?
Anyway, Dr John, God bless you, your family and life changing work in Haiti.

We have “socialized” medicine here in Canada, and in my experience is not only works well but is a mental and physical lifesaver. It has saved millions of lives and kept average people out of astounding debt because they happened to fall ill. We do pay something for it, depending on income, but not much. None of the NEJM problems – “cost of care and its affordability for individuals, the administrative burden (or hassle) that people confront as they obtain and receive care, and disparities or inequities in the delivery of care based on income, educational attainment, race or ethnic background…”- are issues. I also have friends who are doctors, and they are all very comfortably off indeed. I have never heard of anyone telling them what they can or cannot do. And if a patient isn’t happy with their diagnosis or treatment, they can go to another doctor.

I appreciate the input from Ada and Augusta. I am sure each system offers advantages. I am sure ours needs attention. Obamacare was cynically viewed as intentionally designed to fail, so that a clamor for a single-payer system would bring about the real intended outcome.

The above article is much more negative than Augusta’s report on Canada’s system. I do not know enough to discriminate the truth between the two descriptions.

I agree with the statement that whatever Americans choose should be based on accurate information on alternatives.